CPT® Code 21387

1. Indications

The open treatment of an orbital floor blowout fracture using a combined approach is indicated for the following conditions:

• Orbital Floor Fracture: This procedure is performed when there is a fracture of the orbital floor, often resulting from trauma to the mid-facial region.
• Extraocular Muscle Entrapment: Indications include cases where the fracture leads to entrapment of the extraocular muscles, causing restricted eye movement.
• Aesthetic Facial Deformity: The procedure is indicated when there are visible deformities in the facial structure due to the fracture, necessitating surgical intervention for cosmetic restoration.

2. Procedure

The procedure for the open treatment of an orbital floor blowout fracture using a combined approach involves several detailed steps:

• Step 1: Traction sutures are placed in the lower eyelid to facilitate access and manipulation during the surgery.
• Step 2: A pointed scissor is inserted horizontally at the outer lid angle to create an incision along the palpebral fissure, which involves cutting through the skin, orbicularis oculi muscle, and conjunctiva.
• Step 3: The lateral canthal tendon fibers, which fan superficially, are transected to allow for better access to the surgical site. The lower lid is everted using the previously placed traction sutures.
• Step 4: The lateral canthal tendon is completely transected using scissors, freeing the lower eyelid for further surgical intervention.
• Step 5: An incision is made across the length of the lower eyelid in the conjunctiva, just below the base of the tarsus, to facilitate access to the orbital area.
• Step 6: Traction sutures are again placed, and the conjunctiva is pulled superiorly to cover the cornea, protecting it during the procedure.
• Step 7: The plane between the orbital septum and orbicularis muscle is bluntly dissected to reach the orbital rim, allowing for further surgical access.
• Step 8: The periosteum is opened and elevated off the orbital floor, exposing the fracture site for treatment.
• Step 9: The herniated orbital tissue is either removed or repositioned back into the orbit, and the fracture is reduced to restore normal anatomy.
• Step 10: The surgical area is checked for hemostasis to ensure that there is no excessive bleeding before closure.
• Step 11: Sutures are placed into the transected edges of the inferior and superior lateral canthal tendon and are provisionally tightened to secure the eyelid position.
• Step 12: The traction sutures that are positioning the conjunctiva superiorly are cut, and the conjunctiva is repositioned to its original location.
• Step 13: The ends of the lateral canthal tendon sutures are brought out of the conjunctival incision, which is then closed with sutures to secure the area.
• Step 14: The canthal suture is tightened, bringing the lower eyelid back to its original position, ensuring proper alignment and function.
• Step 15: Finally, the subcutaneous tissue of the lateral canthotomy is closed with sutures, followed by the closure of the skin incision to complete the procedure.

3. Post-Procedure

Post-procedure care for patients who have undergone the open treatment of an orbital floor blowout fracture includes monitoring for any signs of complications such as infection or excessive swelling. Patients are typically advised to avoid strenuous activities and to keep the head elevated to reduce swelling. Follow-up appointments are essential to assess healing and to ensure that eye movement is returning to normal. Any prescribed medications, such as pain relievers or antibiotics, should be taken as directed to facilitate recovery. Additionally, patients may be instructed on how to care for the surgical site to promote optimal healing and prevent complications.